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f g 11!= 4.r APPLICATION FOR PERMIT SAN JOAQUI.N LOCAL HEALTH DISTRICT li 1601 E. HAZEL T ON AVE., STOCKTON, CA Its ti Telephone (209) 466-67$1 PERMIT EXPIRES 1'YEAR FROM DATE ISSUED _ I. (Complete in Triplicate) V ) 109G3 I Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. 1n,Ft � !0'� E V�11;.`7iV�C�i AL I-EALI F1 �,VV F ! j�� /V. o f Q , PERMITISLi�ViCES -a Job Address�/`e he-lwee {�" /Qlnu � City `� Lot Size PM j Owner's NameM ! Address �' yY' ' ,65r—: t �� Phone —;2 Contractor t t-ch f)r'r f � P"`^^f Address " A"�l vTi License No 6 � 5 Phones ' Ii �Q TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ / PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER'` /'I!>'7'2I7ar'lr1Qel� DISTANCE TO NEAREST: SEPTIC TANK NA SEWER LINES >50" DISPOSAL FLD. NR PROP. LINE^-ZO FOUNDATION AGRICULTURE WELL n6 OTHER WELL "I0de PITS/SUMPS N INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation / Dia. of Well Casing il. �. ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing v Specifications u i ❑ Public ❑ Other F1 Delta Depth of Grout Seat o Type of Grou0men bele I I Irrigation I?Q..Approxi Depth I I Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material Itop 50') Depth I Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 11 REPAIRIADDITION I.I DESTRUCTION I I (No septic system permitted if public sewer is 1 available within 200 feet.) I Installation will serve: Residence_ Commercial Other f I Number of living units: Number of bedrooms �! ; Character of sail to a depth of 3 feet Water table depth SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments I" I PKG. TREATMENT PLT. ❑ I Method of Disposal I 4 i� Distance to nearest: Well Foundation Property Line �( LEACHING LINE ❑ No. & Length of lines Total length/size ) FILTER BED ❑ Distance to nearest: Well Foundation Property Line SEEPAGE PITS I 1 Depth Size Number SUMPS ❑ Distance to nearest: Well Foundation - Property Line ' DISPOSAL PONDS ❑ 1666 I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. I!: Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as 10;become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued, i shall employ persons subject to workman's compensa- tion laws of California." } The applicant m st call for all required inspections. Complete drawing on reverse side. P�ICQm`tS /�Q�i�Se /A is i Signed r Title: �_- `-' _,.4ate: 1I F EP NT USE ONLY Application Accepted by Date Area �� r ` Pit or Grout Inspection by Date Final Inspection by Date Additional Comments: ;I ❑ Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 l Applicant - Return all copies to: Enviror;mental Health Permit/Services 1601 E. Hazelton Ave., P,O, flax 2009, Stk., CA 95201 FEEAMOUNT DUE 1 AMOUNT REMITTED RECEIVED BY DATE PERMIT'NO. INFO +.EH 13-24/REV. n 51 L ,�'�..' , ' PPli�a is eSt/� dao ,5 rrr)P, Owner l's r a 1;Dm, rillreet"Oetoo